Provider Demographics
NPI:1699825786
Name:INGALLS PROF PHARMACY LL
Entity Type:Organization
Organization Name:INGALLS PROF PHARMACY LL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WITVOET
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:708-915-5166
Mailing Address - Street 1:6701 159TH ST
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-1758
Mailing Address - Country:US
Mailing Address - Phone:708-915-7550
Mailing Address - Fax:
Practice Address - Street 1:6701 159TH ST
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1758
Practice Address - Country:US
Practice Address - Phone:708-915-7550
Practice Address - Fax:708-915-7507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-0151553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1476933OtherNABP NUMBER
1476933OtherNABP NUMBER